Guest Post by Helen Clint @dentalmummy

How you choose to feed your baby is a personal choice based on the needs of your baby, yourself and the rest of your family, and as healthcare professionals, we respect the choice that you have made and will support you through that decision. Whether you have chosen to breastfeed or bottle feed, or a combination of both, it is important to take good care of your baby’s teeth when they start to come through, and start thinking about them even before they do!

Healthy habits from the start

Healthy dental habits should start early because tooth decay can begin to develop as soon as the first tooth comes through. I’m a dentist, but I am a mum too, so I know myself how hard it can be to cut through the reams of information that parents are bombarded with. My aim is to educate and empower families to make informed decisions based largely on evidence based research and try and answer the most common questions and anxieties that parents have related to infant (milk) feeding and dental health. Some of the information, particularly around breastfeeding and nocturnal breastfeeding, is confusing and conflicting so I understand why there is so much worry amongst parents. If you experience any feeding challenges because of, for example, tongue tie, latch difficulties or bottle refusal, be sure to seek advice from an appropriate healthcare professional such as your midwife or Health Visitor. Help is invaluable and you can get advice on methods such as cup-feeding with a mini open cup which may be a useful option to support you through the tricky times.

Firstly, I am going to look at breastfeeding

• Exclusive breastfeeding is recommended for around the first 6 months of life, breastfeeding provides the best nutrition for babies. Complementary foods should be introduced from around 6 months of age alongside continued breastfeeding
• Breastfeeding up to 12 months of age is associated with a decreased risk of tooth decay, and it may also be protective. Antibodies in breastmilk may help to impede bacterial growth (including the bacterium that causes tooth decay). Lactoferrin, a protein in breastmilk, may actually kill these bacteria and they may not be able to use lactose, the sugar found in breastmilk, as readily as sucrose, found in some formulas
• You don’t have to stop breastfeeding when your baby gets teeth if you don’t want to!
• But….breastfed babies can still get cavities! Breast milk (like formula) contains natural sugars. For tooth decay to form, there needs to be two elements present in the mouth over a period of time: bacteria that cause tooth decay and simple carbohydrates (in the form of free sugars-this is the case when babies start complementary foods)

Night-feeding

There is confusion around night time feeding, particularly beyond 12 months – there is some emerging evidence suggesting that beyond 12 months breastfeeding may no longer have a protective effect and may put children at an increased risk of dental caries but the evidence is not strong and there needs to be more research in this area.

WHO guidelines advise breastfeeding up to 2 years and beyond (but these guidelines are currently under review). There are clear benefits associated with breast feeding for both mother and baby.

Long-term and on-demand breastfeeding may be a risk factor for early childhood caries (ECC-this is the term to describe the presence of one or more decayed or filled tooth surfaces in a young child under 6 years of age), but, along with the inconclusive nature of the evidence related to dental decay and the known benefits of breastfeeding, this should be discussed with parents on an individual basis in order to allow them to make informed decisions about what is best for them, their child and family, taking any risk factors into account. The amount and frequency of consumption of free sugars is the main causative factor in dental caries. Some of the emerging evidence indicates that breastfeeding on demand through the night after the age of one may carry an increased risk of dental decay, but many studies have not taken into account wider factors, such as types of foods consumed and how frequently these are consumed and if sufficient toothbrushing practices are in place-so it is difficult to determine if nocturnal breastfeeding alone is the sole causative main risk factor for ECC.

Dental caries

Dental caries (decay) is a complex, multifactorial disease-meaning that there are many potential causes. When infants are no longer exclusively breast or formula fed, confounding factors (variables which often aren’t controlled) such as the consumption of potentially decay causing drinks and foods and tooth brushing practices (with appropriate fluoride toothpastes), need to be taken into account when investigating the impact of infant feeding practices. For me personally, dental health would not be the sole reason to stop breastfeeding, it would be a choice I would make based on my baby’s needs and my own, as in addition to being a potential risk factor for dental decay, breastfeeding has lots of other benefits too! With regards to dental health, what I would advise is being aware of your child’s diet and habits in terms of brushing, dental visits and snacking, particularly around ‘healthy’ snacks as these factors are more likely to contribute to ECC rather than breastfeeding alone, but watch this space for any updates to official advice on feeding children beyond the age of one!

Feeding to sleep?

It’s normal and common for children to breastfeed to sleep – where breastfeeding is different to bottle feeding, the breast will not release milk unless actively sucked, so the milk is less likely to pool in your little ones mouth. In breastfeeding the sucking and swallowing minimises contact between the teeth and milk but the exception to this is during ‘let downs’ (release of your breast milk) which may happen randomly. If let downs occur at night when baby is asleep at the breast, there will be a pooling of milk in the mouth and the time that milk is in contact with teeth may be increased. At night time and when we sleep, saliva which neutralises the acidic state of the mouth is less abundant. So to maintain dental health, consider taking your little one from the breast when asleep (to avoid random letdowns) and wiping any pooled milk from their gums, lips and mouth, with a clean muslin or there are also dental wipes on the market too.

Beyond 12 months consider:

• Cleaning teeth thoroughly before nocturnal breastfeeding
• Make toothbrushing before bed part of your child’s evening routine. Over the age of one, the last thing to touch a child’s teeth at bedtime should be a fluoride toothpaste. You should ideally wait at least 30 minutes after the last food or drink to brush your child’s teeth, BSPD advise a ‘golden hour’ after the age of one when children have nothing to eat or drink except water, and teeth should be brushed just before they go to bed
• Breastfeeding less frequently or keeping feeds to mealtimes, and avoid feeding to sleep (easier said than done!)

If you are ready to stop night feeding, some tips for night weaning include:

• Ensuring your little one is eating well through the day so they aren’t as hungry at night
• Try cuddles, talking and singing to baby to get them back to sleep rather than offering your breast every time they wake or consider someone else offering the night time comfort
• Remember some babies do not want to give up breastfeeding so it is best to wait until you are both ready!

Bottle feeding

Early childhood caries, formerly known as nursing or bottle caries is a form of tooth decay that can be caused by children sleeping with bottles. It is caused when a child goes to bed with a bottle filled with milk or juice-anything except water. It usually affects children between the ages of one and two years. (There is also emerging evidence to show that Breastfed infants who fall asleep while breastfeeding are also at risk). It can also occur when children are allowed to frequently drink anything other than water from a sippy cup or bottle during the day or night

The following are the most common signs and symptoms of nursing caries:

• White spots at the gum line of upper front teeth
• Early development of cavities (brown areas on the tooth that lead to tooth destruction)
• Parents who are bottle feeding are strongly advised to withdraw the bottle by the age of one, particularly for night time feeding.
• The evidence in favour of stopping bottle feeding by the age of one has been strong for some time

Introduce a cup

From six months, an open-topped or free-flow cup should be introduced (these are different to ‘sippy’ cups). It may take several attempts for your baby to master the art of drinking from a cup as it will feel totally different to a teat or a nipple, but persevere! Drinking from a cup is less likely to cause liquid to collect around the teeth. Also, a cup cannot be taken to bed. With the right sized cup for your little one, open cup drinking is easily achievable and can make you so proud and so happy seeing your little one starting their healthy sipping habit! NHS guidance states that once your baby is 1 year old, feeding from a bottle should be discouraged. (If you’ve been breastfeeding: when you are no longer exclusively breastfeeding, you can bypass using a bottle and go straight to using an open cup).

Extra fluids for bottle fed babies

If you are bottle feeding you may need to give your baby extra fluids, as bottle fed babies can sometimes become constipated. Use cooled boiled water. Never add sugar to the water, as this can have the opposite effect and may lead your baby to have diarrhoea. If used frequently, it can also cause tooth decay and your baby may develop a liking for sweetened drinks.  Stick only to your baby’s usual milk or plain water in their feeding bottle. Never let your baby fall to sleep drinking juice! When a baby falls asleep with a bottle, the teat will continue to leak any remaining bottle contents slowly into the baby’s mouth, prolonging the exposure to teeth.

Steer clear of juice

There are numerous baby juices available in the supermarkets, all claiming to be vital to health and the claims can be very misleading. The truth is the only drinks which are healthy for teeth are milk and plain water. Breast milk, infant formula and water should be the only drinks your child if offered up to 12 months of age. Ensure only your baby’s usual milk or plain water is placed in a baby’s bottle.

After 12 months old, dental health recommendations state that drinks other than milk or water are not recommended for children aged under 5 years. Even drinks which say ‘no added sugar’ or ‘sugar free’ can be damaging to teeth, and can also give little ones a preference for sweet tastes too.

Sippy not sucky

Try to avoid “No spill” cups as these can be similar to bottles in terms of encouraging frequent use and can also have a negative impact on your baby’s speech development due to the intense sucking action and the position of the tongue needed to open the valve inside which releases the fluid. No spill cups are not the same as open cups.

Do not use a bottle or sippy cup as a pacifier or let your child walk around with or drink from one for long periods. Another great advantage of using an open cup is they help discourage cups being used as a pacifier. Babycup First Cups by British-brand, Babycup, are a great option as they are specifically designed to be baby-sized and baby-safe.

If your child must have a bottle or sippy cup for long periods or in between meals, fill it with water only.

Feeding and teeth

However you are feeding your little one….

• Brush your child’s teeth 2 times per day for 2 minutes. Use a flat smear of fluoride toothpaste at least 1000ppmF (0-3 years)-we advise brushing before bed and on at least one other occasion.
• Leave at least 30 minutes after eating or drinking before brushing to allow the mouth to return to it’s more neutral pH
• From the age of one, consider introducing a ‘golden hour’ when all your child has in the last hour before bed is water and teeth are cleaned last thing before bed so that the last thing to touch a child’s teeth is a fluoride toothpaste.
• If you are still giving night feeds, wipe any excess or pooled milk from your little ones mouth. Brush Baby make handy packs of dental wipes, also a teething version with added camomile.
• From six months an open-topped or free-flow cup should be introduced (these are not the same as ‘sippy’ cups). Babycup First Cups by Babycup, are open cups specifically designed to be baby-sized and baby-safe.
• Children should receive their first dental check by the age of one – the child should then be seen once a year or more, depending on the advice of your dentist
• Habits such as dummy use and digit sucking should be withdrawn by 12 months.

  Helen Clint is a primary care dentist in general practice in Liverpool. A mum to two young children, Helen understands firsthand the trials and tribulations of trying to do the best for your little ones. Combining her professional knowledge and real life experiences, Helen is passionate about improving children’s oral health and is committed to making information relatable. For more great info and advice, follow Helen on Instagram @dentalmummy